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The Two Americas: Moving Farther Apart?

commonwealth fund blog

The Commonwealth Fund's recently released Scorecard on State Health System Performance, 2014, finds big differences between states on measures of health care access, quality, costs, and outcomes. What's more, its authors warn that these differences could very well widen in the future. Many of the lowest-performing states are choosing not to expand their Medicaid programs under the Affordable Care Act (ACA). Some also are discouraging eligible uninsured citizens from purchasing subsidized coverage through new ACA marketplaces, though some uninsured are signing up nonetheless.

The fact that so many low-performing states are spurning the ACA’s benefits, while high-performing states are rushing to embrace them, raises profound questions for the future of our country. What would it mean if different parts of the United States find themselves on radically different health care trajectories, with some enjoying progressively better health and health care and others falling further and further behind? In other words, what would it mean if the two health care Americas grow further and further apart over time?

This is unexplored territory for health care researchers and policymakers, but we know enough to point to some possibilities.

To begin with, we know that when people have health coverage they live longer, healthier lives. Widening gaps in rates of insurance coverage between low- and high-performing states will almost certainly lead to growing differences in life expectancy and health status. This is worrisome and regrettable, but probably only part of the story.

An equally important—but much less explored—question is whether differing health care trajectories also will lead to differing economic and social trajectories. All else equal (of course, it never precisely is), will regions with poorer health care and health status suffer economically and socially as well? Will they have less productive workforces, less productive economies, and, as result, lower quality of life overall? Will they become less attractive places to live, work, and do business?

Several lines of evidence suggest that diverging regional health care systems could lead to diverging general welfare. First, untreated physical and mental health problems increase workers’ time off from work, reduce performance while at work, and lower rates of employment. In the early 20th century, infections such as yellow fever, malaria, and hookworm greatly hindered the economy of the American South. In his memoir, Jimmy Carter recalls that, while growing up in rural Georgia, “almost everyone was afflicted from time to time with hookworm,” a parasite that causes anemia, malaise, and fatigue. Eventually, public health measures and improved living conditions brought this and other health problems under control, contributing to a burst of economic growth.

A century later, chronic illness is the equivalent of the infectious illness that once disproportionately taxed the economy of the American South. In the United States, annual productivity losses from diabetes and depression alone exceed $100 billion nationally. And we know this burden can be lightened through good primary and preventive care that will be less available in regions with large uninsured populations.

Second, health insurance boosts economies by protecting people against catastrophic out-of-pocket health care expenses. These costs can lead to bankruptcy, which raises the cost of borrowing for the rest of society as lenders take into account the risk that they will not be repaid. Those avoiding bankruptcy often incur substantial medical debt, with far-reaching consequences. A 2012 Commonwealth Fund survey found that 61 percent of uninsured adults ages 19 to 64 reported problems paying their medical bills or said they were paying off medical debt over time. Among these individuals, more than half said they received a lower credit rating as a result of unpaid medical bills, 43 percent used all of their savings to pay their bills, and 29 percent delayed education or career plans. The 2006 Massachusetts health reform, which has led to nearly universal health coverage, has also led to fewer personal bankruptcies and bills past due and improved credit scores, particularly for those with limited access to credit before the reform.

Third, insurance may also confer tangible social benefits. For example, reducing recidivism rates is a high priority for the criminal justice system and society, and states may find it harder to meet this goal if they don’t expand Medicaid. The nation’s prisons have become holding facilities for the mentally ill, but lacking insurance, former mentally ill prisoners are unlikely to get the treatment they need to avoid future incarceration. In states expanding Medicaid, the resulting coverage could help to break this cycle. Proper treatment has been shown to reduce adult offenders’ overall recidivism rates by nearly 7 percent. Evidence suggests that among the most severely mentally ill, Medicaid-funded care could reduce recidivism by up to 16 percent.

Fourth, and somewhat more speculatively, there may be a link between good health care and effective education. Absences from school because of preventable or treatable illnesses, such as asthma, interfere with students’ ability to stay abreast of their studies and, when frequent, can lead to a lifetime of underachievement. To some degree, regions have to live with the workforces their schools produce. As the information revolution puts a higher and higher premium on super-skilled workers, differences in the educational attainment of local workforces could become an increasing source of economic disparity.

Whether the two health care Americas will diverge, by how much, and with what consequences remain uncertain. But one thing is beyond dispute. We are one country. The fates of lower- and higher-performing states are inextricably linked. Citizens move far and wide across the nation. Our states’ economies are interdependent in many ways. We share one Social Security system, one Medicare system, one federal tax system, one balance of trade, and we are defended by one military.

While we revel in our local autonomy and differences, we must recognize when those differences lead to preventable health, economic, and social problems that detract from our collective welfare. The Commonwealth Fund will continue to map the trajectory of the two health care Americas so that the nation can understand and take steps to address their changing circumstances.

Publication Details



David Blumenthal, Former President, The Commonwealth Fund

[email protected]


D. Blumenthal and D. Squires, "The Two Americas: Moving Farther Apart?" The Commonwealth Fund Blog, May 15, 2014.